Abstract
Adult intussusception represents 1% of patients with bowel obstruction and 5% of all intussusception. In contrast to intussusception in children, a demonstrable aetiology is found in 70% to 90% of the patients. It usually presents with symptoms of sub-acute intestinal obstruction. Since the incidence of malignant lesions in these cases is very high (about 48% and 43% in ileal and colonic intussusception) the procedure of choice for treatment of intussusception in adults is resection without reduction.

We report a case of ileo-colic intussusception in 20 year old female where it presented with pain abdomen and symptoms of subacute obstruction. Patient was treated with resection and anastomosis, and on biopsy of the specimen low grade MALT tumour of the ileum was found. Since the patient had Stage-I disease no further treatment was given.

Introduction
A rare occurrence in adults, intussusception exists when a proximal segment of bowel (intussusceptum) telescopes into the lumen of the adjacent distal segment (intussuscipiens). Adult intussusception represents 1% of patients with bowel obstruction and 5% of all intussusception. In contrast to intussusception in children, a demonstrable aetiology is found in 70% to 90% of the patients. It usually presents with symptoms of sub-acute intestinal obstruction but may also present with acute or chronic problems. Pre-operative diagnosis may not always be possible. CT Scan is supposed to be the best diagnostic modality. Since the incidence of malignant lesions in these cases is very high (about 48% and 43% in ileal and colonic intussusception) the procedure of choice for treatment of intussusception in adults is resection without reduction.

A case of lleo-colic intussusception in adult is hereby reported which was diagnosed pre-operatively and treated with resection and anastomosis. The biopsy of specimen revealed low grade MALT tumour of the lleum with clear margins. Since the disease was low grade and localized no further treatment was needed.

Case Report
20 year old married Hindu female presented with pain in abdomen since one month and Abdominal distension off and on with vomiting since one month. Pain was associated with Gola formation and abdominal distension and was relieved by analgesics. There was no h/o anorexia or weight loss and no h/o upper or lower GI bleed. There was no h/o altered bowel habit, DM, HT, or Kochs. Pt. had one male child, two years old.

On examination, she was pale. On per-abdomen examination, Abdomen was soft and non-tender but had an obvious fullness in the Lt. hypochondrium which was extending from just below the Lt. costal margin to the level of the umbilicus. The lump was firm in consistency, non-tender and freely mobile. It was dull on percussion. Per-rectal examination was normal.

Routine investigations of the patient were within the normal limits, except that the Hb was 10.0 with PCV 32.2 and MCH 25.2. Pt. underwent colonoscopy which revealed polypoid growth in mid transverse colon with regional ulceration. No active oozing was seen. Descending colon was normal and probable Diagnosis of Ca. Colon was given. On CECT Abdomen, caecum was absent, the iliac fossa and gut seen within the large gut in the region of hepatic flexure. Transverse colon was oedematous while the descending colon was normal. No mass could be detected.

Fig. 1 : Intussuscepting ileum coming out of caecum.	Fig. 2 : Mucosal surface of ileum, caecum and colon. (Note thickened ileal wall with granulations).

Pt. was planned for exploratory laparotomy, and per-operatively ileo-colonic intussusception was found reaching upto the splenic flexure. Externally no pathology could be appreciated and the intussusception was reducing easily. On reaching the mid-ascending colon there was slight difficulty in reduction, and so no further reduction was attempted, rather resection and ileo-ascending anastomosis was done in two layers.

Biopsy of the specimen was suggestive of low grade lymphoma of mucosa associated lymphoid tissue. Tumour was infiltrating upto the muscularis mucosa and resected ends were free.

Patient had excellent post-operative recovery. She was started on oral sips from Day - 4 of surgery. Drain was removed on Day 5 and she was fully oral from Day 6 Stitches were removed on Day 8, stitch line was healthy and patient was discharged on the same day.

Discussion
Although intussusception is primarily a disease of children, about 5 per cent of cases occur in adults. The majority of cases in adults are chronic or subacute in nature. The most common clue to diagnosis in the adult is a history suggesting intermittent partial bowel obstruction. Other signs and symptoms, such as blood in stool, palpable mass, and cramping abdominal pain occurs much less frequently in adults than children. Ninety per cent of adults with intussusception have an associated pathological process such as benign or malignant tumours, inflammatory lesions and Meckel’s diverticulum. Prior to 1954 treatment advocated for intussusception was manual reduction before definitive treatment. In 1954 Brayton and Norris emphasized the high incidence of associated malignancy and discouraged manual reduction prior to resection, especially in colonic intussusception. At laparotomy the treatment of choice for all intussusception in adults is resection without any attempt at manual reduction whenever possible. This does not mean removal of such lengths of the gastrointestinal tract as would result in malabsorption syndromes. Each case should be carefully individualized at the time of surgery.

The surgical approach is influenced by four major considerations: a) The frequency of underlying aetiological procedure, itself requiring operative therapy. b) The prevalence of associated malignancy and the implications of any undue operative manipulations at the time of reduction. c) The anatomical site and extent of intussuscetion. d) Various local, intra-operative factors such as, degree of associated inflammation, oedema, and relative ischaemia of the involved bowel. In a recent series 93% patients had an organic lesion identified within the intussusception. Approximately 46% of all patients with intussusception had an underlying malignancy. CT Scan is most accurate and has shown intussusception in upto 78% of cases. Although not pathognomonic, intussusception has been described as a ‘target mass’ on both CT and ultrasound. The intussusceptum is the centre and the oedematous intussuscipiens forms the external ring. Early intussusceptions are target masses associated with obstruction. As the bowel thickens, there is more bowel layering. Finally the bowel necroses and appears as an amorphous mass associated with severe obstruction.

Aetiology of intussusception in adults.

Enteric

• Benign : Post-operative, Meckel’s, Lipoma
  
• Malignant : Metastatic melanoma, Lymphomas, Adenocarcinoma.
  

• Benign : Lipoma, Adenoma, Lymphoid Hyperplasia.
  
• Malignant : Adenocarcinoma, Lymphoma.

References

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